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Letters   |    
Increased Sensitivity to Atypical Antipsychotics in a Patient With Dandy-Walker Variant With Schizophrenia
Aninda Sidana, M.B.B.S.; Sukanto Sarkar, M.B.B.S., M.D., D.P.M.; Sivaprakash Balasundaram, M.B.B.S., M.D.; Samir Kumar Praharaj, M.B.B.S., M.D., D.P.M.
The Journal of Neuropsychiatry and Clinical Neurosciences 2013;25:E31-E32. doi:10.1176/appi.neuropsych.12070162
View Author and Article Information

Dept. of Psychiatry Mahatma Gandhi Medical College and Research Institute Puducherry, India
Dept. of Psychiatry Kasturba Medical College Manipal, Karnataka, India

Copyright © 2013 American Psychiatric Association

To the Editor: Dandy-Walker variant, characterized by cerebellar hypoplasia without marked expansion of the posterior fossa, has been classified as a continuum of Dandy-Walker malformation. We report a case of a Dandy-Walker variant in association with schizophrenia, in which there was worsening of tardive dyskinesia with low doses of atypical antipsychotics.

The Dandy-Walker malformation is a congenital brain malformation characterized by cystic dilatation of the fourth ventricle, dysgenesis of the cerebellar vermis, and higher position of tentorium.1 Less severe conditions, such as Dandy-Walker variant (cerebellar hypoplasia without marked expansion of the posterior fossa), and mega cisterna magnum (expanded posterior fossa with relatively minor hypoplasia of the cerebellum) have been classified as a continuum of Dandy-Walker malformation and named as “Dandy-Walker complex.”1 Various neuropsychiatric disorders have been reported with Dandy-Walker complex, such as schizophrenia-like psychosis, obsessive-compulsive disorder, and bipolar disorder.26 We report a case of a Dandy-Walker variant in association with schizophrenia; this patient had worsening of tardive dyskinesia with low doses of atypical antipsychotics.

“Mr A.,” a 20-year-old man, presented with a history of smiling and muttering to himself, remaining aloof, with occasional abusive and aggressive behavior, and not doing any work for the past 6 years. He was treated with several typical antipsychotics previously without much benefit. He had had an episode of febrile convulsion at 2 years of age, and one younger brother had seizure disorder. Mental status examination revealed silly smiling, with inappropriate affect. On physical examination, he had fine peri-oral dyskinetic movements associated with pouting movements seen infrequently over the lips. The score on the Abnormal Involuntary Movement Scale (AIMS)7 was 4. There were no other neurological signs. His blood investigations, including hemogram, liver and renal function tests, blood sugar, lipid profile, serum electrolytes, and thyroid function tests were normal. Considering a diagnosis of schizophrenia with drug-induced dyskinesia, he was put on olanzapine, an atypical antipsychotic, at 10 mg per day, but peri-oral dyskinetic movements increased in frequency within a few days. Olanzapine was discontinued, and he was put on aripiprazole 10 mg per day, with which he showed improvement in psychotic symptoms, but involuntary movements persisted. Aripiprazole was gradually reduced to 2.5 mg per day, and there was a reduction in the frequency of dyskinetic movements, with an AIMS rating score of 2. A Computerized Tomographic scan of brain revealed mild a radiological-diagnosis dilated fourth ventricle, with hypoplasia of cerebellar vermis, without any posterior fossa cyst (Figure 1), which suggested Dandy-Walker variant.

 
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FIGURE 1.CT Scan of Brain, Showing Mild Dilated Fourth Ventricle With Hypoplasia of Cerebellar Vermis Without a Posterior Fossa Cyst

Our case had radiological features suggestive of Dandy-Walker variant, along with schizophrenia. There has been only one previous report of early-onset schizophrenia with obsessive-compulsive disorder with Dandy-Walker variant.3 Cerebellar abnormalities have been known to occur in schizophrenia, and such associations could shed further insights into the neurobiological underpinnings.8

Tardive dyskinesia (TD) is characterized by bucco-lingual-masticatory movements and most commonly associated with long-term use of typical antipsychotics, and rarely by atypical antipsychotics.9 Moreover, improvement in dyskinetic movements has been reported to occur with atypical antipsychotics such as olanzapine10 and aripiprazole.11 Nevertheless, there are few case reports of TD with aripiprazole in patients with schizophrenia, bipolar disorder, and refractory depression;12 and, in one case report, aripiprazole-induced TD improved upon discontinuation of medication.13 Our case had drug-induced TD, and there was exacerbation of dyskinesia with addition of atypical antipsychotics. Furthermore, the dyskinetic movements improved after discontinuing olanzapine and reducing the dose of aripiprazole, which suggests an increased tendency to develop abnormal movements with atypical antipsychotics in patients with schizophrenia having an organic pathology. Interestingly, in a previous report,5 a 10-year-old boy having mania associated with Dandy Walker variant was treated successfully with a combination of olanzapine and valproate without any emergent extrapyramidal adverse effect. It is possible that only those with Dandy-Walker variant with pre-existing TD may be uniquely sensitive to adverse effects of atypical antipsychotics, as seen in our case. Also, the above case points toward the role of cerebellum in the abnormal sensitivity to low-dose atypical antipsychotics. It seems prudent to investigate using neuroimaging in young patients showing sensitivity to low doses of atypical antipsychotics.

Barkovich  AJ;  Kjos  BO;  Norman  D  et al:  Revised classification of posterior fossa cysts and cyst-like malformations based on the results of multiplanar MR imaging.  AJR Am J Roentgenol 1989; 153:1289–1300
[CrossRef] | [PubMed]
 
Langarica  M;  Peralta  V:  [Psychosis associated to megacisterna magna].  An Sist Sanit Navar 2005; 28:119–121
[PubMed]
 
Papazisis  G;  Mastrogianni  A;  Karastergiou  A:  Early-onset schizophrenia and obsessive-compulsive disorder in a young man with Dandy-Walker variant.  Schizophr Res 2007; 93:403–405
[CrossRef] | [PubMed]
 
Li  H;  Chen  Q;  Liu  W:  Adult asymptomatic case of Dandy-Walker syndrome associated with bipolar disorder.  Acta Neuropsychiatr 2008; 20:170–171
[CrossRef]
 
Lingeswaran  A;  Barathi  D;  Sharma  G:  Dandy-Walker variant associated with bipolar affective disorder.  J Pediatr Neurosci 2009; 4:131–132
[CrossRef] | [PubMed]
 
Aimua  F;  Dunn  NR;  Swift  RG:  Dandy-Walker variant with treatment-resistant bipolar disorder.  J Neuropsychiatry Clin Neurosci 2012; 24:E50
[CrossRef] | [PubMed]
 
Guy  D: Abnormal Involuntary Movement Scale, in ECDEU Assessment Manual for Psychopharmacology, Revised Edition. (DHEW Publication: (ADM) 76-338). Rockville, MD: National Institute of Mental Health; 1976
 
Andreasen  NC;  Pierson  R:  The role of the cerebellum in schizophrenia.  Biol Psychiatry 2008; 64:81–88
[CrossRef] | [PubMed]
 
van Harten  PN;  Tenback  DE:  Tardive dyskinesia: clinical presentation and treatment.  Int Rev Neurobiol 2011; 98:187–210
[PubMed]
 
Kinon  BJ;  Jeste  DV;  Kollack-Walker  S  et al:  Olanzapine treatment for tardive dyskinesia in schizophrenia patients: a prospective clinical trial with patients randomized to blinded dose-reduction periods.  Prog Neuropsychopharmacol Biol Psychiatry 2004; 28:985–996
[CrossRef] | [PubMed]
 
Duggal  HS:  Aripiprazole-induced improvement in tardive dyskinesia.  Can J Psychiatry 2003; 48:771–772
[PubMed]
 
Maytal  G;  Ostacher  M;  Stern  TA:  Aripiprazole-related tardive dyskinesia.  CNS Spectr 2006; 11:435–439
[PubMed]
 
Abbasian  C;  Power  P:  A case of aripiprazole and tardive dyskinesia.  J Psychopharmacol 2006; 20:592–593
[CrossRef] | [PubMed]
 
References Container

FIGURE 1. CT Scan of Brain, Showing Mild Dilated Fourth Ventricle With Hypoplasia of Cerebellar Vermis Without a Posterior Fossa Cyst
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References

Barkovich  AJ;  Kjos  BO;  Norman  D  et al:  Revised classification of posterior fossa cysts and cyst-like malformations based on the results of multiplanar MR imaging.  AJR Am J Roentgenol 1989; 153:1289–1300
[CrossRef] | [PubMed]
 
Langarica  M;  Peralta  V:  [Psychosis associated to megacisterna magna].  An Sist Sanit Navar 2005; 28:119–121
[PubMed]
 
Papazisis  G;  Mastrogianni  A;  Karastergiou  A:  Early-onset schizophrenia and obsessive-compulsive disorder in a young man with Dandy-Walker variant.  Schizophr Res 2007; 93:403–405
[CrossRef] | [PubMed]
 
Li  H;  Chen  Q;  Liu  W:  Adult asymptomatic case of Dandy-Walker syndrome associated with bipolar disorder.  Acta Neuropsychiatr 2008; 20:170–171
[CrossRef]
 
Lingeswaran  A;  Barathi  D;  Sharma  G:  Dandy-Walker variant associated with bipolar affective disorder.  J Pediatr Neurosci 2009; 4:131–132
[CrossRef] | [PubMed]
 
Aimua  F;  Dunn  NR;  Swift  RG:  Dandy-Walker variant with treatment-resistant bipolar disorder.  J Neuropsychiatry Clin Neurosci 2012; 24:E50
[CrossRef] | [PubMed]
 
Guy  D: Abnormal Involuntary Movement Scale, in ECDEU Assessment Manual for Psychopharmacology, Revised Edition. (DHEW Publication: (ADM) 76-338). Rockville, MD: National Institute of Mental Health; 1976
 
Andreasen  NC;  Pierson  R:  The role of the cerebellum in schizophrenia.  Biol Psychiatry 2008; 64:81–88
[CrossRef] | [PubMed]
 
van Harten  PN;  Tenback  DE:  Tardive dyskinesia: clinical presentation and treatment.  Int Rev Neurobiol 2011; 98:187–210
[PubMed]
 
Kinon  BJ;  Jeste  DV;  Kollack-Walker  S  et al:  Olanzapine treatment for tardive dyskinesia in schizophrenia patients: a prospective clinical trial with patients randomized to blinded dose-reduction periods.  Prog Neuropsychopharmacol Biol Psychiatry 2004; 28:985–996
[CrossRef] | [PubMed]
 
Duggal  HS:  Aripiprazole-induced improvement in tardive dyskinesia.  Can J Psychiatry 2003; 48:771–772
[PubMed]
 
Maytal  G;  Ostacher  M;  Stern  TA:  Aripiprazole-related tardive dyskinesia.  CNS Spectr 2006; 11:435–439
[PubMed]
 
Abbasian  C;  Power  P:  A case of aripiprazole and tardive dyskinesia.  J Psychopharmacol 2006; 20:592–593
[CrossRef] | [PubMed]
 
References Container
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